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Willing hands . . .

When it comes to death, Thornton Wilder was indisputably right: you can’t
take anything with you. But how do we feel about leaving behind the most
personally significant bits of our bodies for others to use when we have
died?

As a healthcare lawyer and bioethicist, I find it curious that nobody is
asking this question, for we have surely entered a new era of transplant surgery
where hands, faces and even sex organs could be donated to strangers in need,
just as hearts, kidneys and livers are donated now. Clint Hallam’s famous hand
transplant in Lyons in September 1998 was soon followed by news that an American
team in Louisville had transplanted a hand, and intends to transplant 10 more in
the near future.

If the hand transplants prove successful, even the faces of the dead could
some day grace living recipients who have suffered catastrophic burn injuries.
Only last autumn Nicolo Scuderi, a surgeon based in Rome, applied for permission
to transplant penises as part of three sex-change operations.

These transplants raise a serious policy question. The success of mainstream
transplant surgery has spawned a vexing problem—the ever-widening gap
between the number of people in need of “the gift of life” and those suitable
and willing to be organ donors. As of 2 June, there were 63 635 people on the
waiting list in the US with a new name added every 16 minutes. When people hear
about face and penis transplants, could the “yuck factor” deter them from
filling out donor cards, thus making a bad situation worse?

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By now, you’d think we would have a good idea of how the public feels. But we
don’t. I could find no empirical data in the literature, no responses from the
public to carefully crafted questionnaires assessing their reaction to
transplants of hands, arms, faces and penises. Perhaps most experts think no new
emotions will be stirred. If so, they may be wrong at our peril.

Our hands, second only to our faces, introduce us to the world. We shake
hands when we meet others and gesture to express our emotions. We caress those
we love. The idea of a transplanted hand—bringing with it the essence of
the person whose hand it once was—is a staple of horror films or science
fiction. And face transplants are even more likely to carry with them a sense of
the hijacking of someone’s personal identity.

Of course, such feelings are irrational. Unless the facial bones are
transplanted as well, recipients are unlikely to look like the donor. But
medical pioneers and policy makers ought to deal with people’s emotions as they
are, not as they would like them to be. What’s more, unlike all existing
transplants, hand and face transplants will result in obvious disfigurement of
the donor’s corpse.

Liz Reed, regional director of Kentucky Organ Donor Affiliates, has the job
of finding the 10 hands that the Louisville team. In many countries, including
the US, families of dead potential donors have the final say. To minimise the
impact of hand transplants on donation of vital organs, Reed says she will only
ask families for hands after they have been approached for organs and other
tissues. Clearly, this is a prudent policy, but it may not help much if people
turn against organ donation before they die and tell their families of their
change of view.

In many places round the world, people prefer open-casket funerals.
Ironically, the makers of the artificial hand that was recently replaced by a
real one by the Louisville team are now offering their services to the families
of donors. Indeed, they have already fashioned one hand for a corpse. Artificial
hands may be going out of fashion for the living, but not, it seems, for the
dead.